{!! admin_css('vendor/dcat-admin/dcat/plugins/bootstrap-datetimepicker/bootstrap-datetimepicker.min.css?v2.2.2-beta') !!}
{!! admin_css('vendor/dcat-admin/dcat/plugins/select/select2.min.css?v2.2.2-beta') !!}
{!! admin_css('vendor/dcat-admin/dcat/extra/upload.css?v2.2.2-beta') !!}

<div class="content-body fitness-form" id="app">
    <div class="row">
        <div class="col-md-12">
            <form method="post" enctype="multipart/form-data" accept-charset="UTF-8"
                  action="{{ url('admin/add_user_health_2') }}" class="" id="form-fitness">
                <!-- hidden value -->
                {{ csrf_field() }}
                <input type="hidden" value="{{ $userId }}" name="user_id"/>
                @if(!empty($form))
                    <input name="form_id" hidden value="{{ $form->id }}">
                @endif

                <div class="card">
                    <!-- 头部 -->
                    <div class="box-header with-border mb-1" style="padding: .65rem 1rem">
                        <h3 class="box-title" style="line-height:30px;">健康管理档案</h3>
                        <div class="pull-right">
                            <div class="btn-group pull-right" style="margin-right: 5px">
                                <a href="#" class="btn btn-sm btn-primary "><i class="feather icon-list"></i><span
                                        class="d-none d-sm-inline">&nbsp;列表</span></a>
                            </div>
                        </div>
                    </div>

                    <!-- body -->
                    <div class="box-body" style="margin-top: 6px">
                        <div class="fields-group">
                            <div class="row">
                                <!-- 表单逻辑代码 -->
                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>姓名</span></div>
                                        <div class="col-md-8 ">
                                            <div class="help-block with-errors"></div>
                                            <div class="input-group">
                                            <span class="input-group-prepend"><span class="input-group-text bg-white"><i
                                                        class="feather icon-edit-2"></i></span></span>
                                                <input type="text" name="name" value="{{ $user?->name }}"
                                                       required disabled
                                                       class="form-control field_name _normal_" placeholder="输入 姓名">
                                            </div>
                                        </div>
                                    </div>

                                    <div class="form-group row form-field">


                                        <div class="col-md-2 text-capitalize control-label"><span>性别</span></div>
                                        <div class="col-md-8 ">
                                            <div class="help-block with-errors"></div>
                                            <div class="input-group">
                                            <span class="input-group-prepend"><span class="input-group-text bg-white"><i
                                                        class="feather icon-user"></i></span></span>
                                                <select name="gender" class="form-control" disabled>
                                                    <option
                                                        value="0" {{ $user && $user->gender == 0 ? 'selected' : '' }}>女
                                                    </option>
                                                    <option
                                                        value="1" {{ $user && $user->gender == 1 ? 'selected' : '' }}>男
                                                    </option>
                                                </select>
                                            </div>
                                        </div>

                                    </div>

                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>联系电话</span></div>
                                        <div class="col-md-8 ">
                                            <div class="help-block with-errors"></div>
                                            <div class="input-group">
                                            <span class="input-group-prepend"><span class="input-group-text bg-white"><i
                                                        class="feather icon-phone"></i></span></span>
                                                <input type="text" disabled name="phone" value="{{ $user?->phone }}"
                                                       class="form-control field_name _normal_" placeholder="输入 联系电话">
                                            </div>
                                        </div>

                                    </div>

                                    {{--                                    <div class="form-group row form-field">--}}
                                    {{--                                        <div class="col-md-2 text-capitalize control-label"><span>生日</span></div>--}}
                                    {{--                                        <div class="col-md-8 ">--}}
                                    {{--                                            <div class="help-block with-errors"></div>--}}
                                    {{--                                            <div class="input-group">--}}
                                    {{--                                                <span class="input-group-prepend"><span--}}
                                    {{--                                                        class="input-group-text bg-white"><i--}}
                                    {{--                                                            class="fa fa-calendar fa-fw"></i></span></span>--}}
                                    {{--                                                <input disabled style="width: 200px;flex:none" type="text" name="birthday"--}}
                                    {{--                                                       value="{{ $user?->birthday }}" class="form-control field_birthday _normal_"--}}
                                    {{--                                                       placeholder="输入 birthday">--}}
                                    {{--                                            </div>--}}
                                    {{--                                        </div>--}}
                                    {{--                                    </div>--}}


                                </div>
                                <!-- 左列结束 end -->

                                <!-- 右列 start -->
                                <div class="col-md-6">

                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>体重</span></div>
                                        <div class="col-md-8 ">
                                            <div class="help-block with-errors"></div>
                                            <div class="input-group">
                                            <span class="input-group-prepend"><span class="input-group-text bg-white"><i
                                                        class="feather icon-edit-2"></i></span></span>
                                                <input type="text" name="arm_cir_right"
                                                       value="{{ $user->fitnessForm?->weight }}"
                                                       disabled
                                                       class="form-control field_name _normal_" placeholder="输入 右臂围">
                                            </div>
                                        </div>
                                    </div>

                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>年龄</span></div>
                                        <div class="col-md-8 ">
                                            <div class="help-block with-errors"></div>
                                            <div class="input-group">
                                                <span class="input-group-prepend"><span
                                                        class="input-group-text bg-white"><i
                                                            class="fa fa-calendar fa-fw"></i></span></span>
                                                <input style="width: 200px;flex:none" type="text" name="age"
                                                       value="{{ $age }}" class="form-control "
                                                       disabled
                                                       placeholder="年龄">
                                            </div>
                                        </div>
                                    </div>

                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>出生日期</span></div>
                                        <div class="col-md-8 ">
                                            <div class="help-block with-errors"></div>
                                            <div class="input-group">
                                                <span class="input-group-prepend"><span
                                                        class="input-group-text bg-white"><i
                                                            class="fa fa-calendar fa-fw"></i></span></span>
                                                <input style="width: 200px;flex:none" type="text" name="age"
                                                       value="{{ $user?->birthday }}" class="form-control "
                                                       disabled
                                                       placeholder="出生日期">
                                            </div>
                                        </div>
                                    </div>


                                </div>
                                <!-- 右列 end -->


                            </div>

                            <hr/>
                            <div class="row">

                                <div class="col-md-12">

                                    <div class="form-group row form-field">
                                        <div class="col-md-1 text-capitalize control-label"><span>病史</span></div>
                                        <div class="col-md-11 ">
                                            <div class="help-block with-errors"></div>
                                            <div class="input-group">

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="history_chd"
                                                           @if(!empty($form->history_chd)) checked @endif
                                                           class="field_history_chd _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                    <span class="vs-checkbox--check"><i
                                                            class="vs-icon feather icon-check"></i></span></span>
                                                    <span>冠心病</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="history_ap"
                                                           @if(!empty($form->history_ap)) checked @endif
                                                           class="field_history_ap _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                    <span class="vs-checkbox--check"><i
                                                            class="vs-icon feather icon-check"></i></span></span>
                                                    <span>心绞痛</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="history_htn"
                                                           @if(!empty($form->history_htn)) checked @endif
                                                           class="field_history_htn _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                    <span class="vs-checkbox--check"><i
                                                            class="vs-icon feather icon-check"></i></span></span>
                                                    <span>高血压</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="history_dm"
                                                           @if(!empty($form->history_dm)) checked @endif
                                                           class="field_history_dm _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                    <span class="vs-checkbox--check"><i
                                                            class="vs-icon feather icon-check"></i></span></span>
                                                    <span>糖尿病</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="history_bih"
                                                           @if(!empty($form->history_bih)) checked @endif
                                                           class="field_history_bih _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                    <span class="vs-checkbox--check"><i
                                                            class="vs-icon feather icon-check"></i></span></span>
                                                    <span>脑梗</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="history_sss"
                                                           @if(!empty($form->history_sss)) checked @endif
                                                           class="field_history_sss _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                    <span class="vs-checkbox--check"><i
                                                            class="vs-icon feather icon-check"></i></span></span>
                                                    <span>中风后遗症</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="history_cso"
                                                           @if(!empty($form->history_cso)) checked @endif
                                                           class="field_history_cso _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                    <span class="vs-checkbox--check"><i
                                                            class="vs-icon feather icon-check"></i></span></span>
                                                    <span>颈椎病</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="history_lrp"
                                                           @if(!empty($form->history_lrp)) checked @endif
                                                           class="field_history_lrp _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                    <span class="vs-checkbox--check"><i
                                                            class="vs-icon feather icon-check"></i></span></span>
                                                    <span>腰腿病</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="history_gout"
                                                           @if(!empty($form->history_gout)) checked @endif
                                                           class="field_history_gout _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                    <span class="vs-checkbox--check"><i
                                                            class="vs-icon feather icon-check"></i></span></span>
                                                    <span>痛风</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="history_ra"
                                                           @if(!empty($form->history_ra)) checked @endif
                                                           class="field_history_ra _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                    <span class="vs-checkbox--check"><i
                                                            class="vs-icon feather icon-check"></i></span></span>
                                                    <span>风湿关节炎</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="history_cg"
                                                           @if(!empty($form->history_cg)) checked @endif
                                                           class="field_history_cg _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                    <span class="vs-checkbox--check"><i
                                                            class="vs-icon feather icon-check"></i></span></span>
                                                    <span>慢性胃病</span>
                                                </div>

                                                <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                    <input type="text" name="history_other"
                                                           value="{{ $form?->history_other }}"
                                                           class="form-control field_name _normal_" placeholder="输入 其他">
                                                </div>

                                            </div>
                                        </div>
                                    </div>


                                </div>
                            </div>

                            <div class="row">
                                <div class="col-md-12">
                                    <hr/>
                                </div>
                            </div>

                            <div class="row">
                                <div class="col-md-12">
                                    <h4 class="text-center">病状</h4>
                                    <hr/>
                                </div>
                            </div>

                            <div class="row">
                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>形体</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_xt_pp"
                                                           @if(!empty($form->ill_xt_pp)) checked @endif
                                                           class="field_ill_xt_pp _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>偏胖</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_xt_ps"
                                                           @if(!empty($form->ill_xt_ps)) checked @endif
                                                           class="field_ill_xt_ps _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>偏瘦</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_xt_bz"
                                                           @if(!empty($form->ill_xt_bz)) checked @endif
                                                           class="field_ill_xt_bz _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>标准</span>
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                <input type="text" name="ill_xt_ot" value="{{ $form?->ill_xt_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>说话声音</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_sy_dr"
                                                           @if(!empty($form->ill_sy_dr)) checked @endif
                                                           class="field_ill_sy_dr _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>声音低弱</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_sy_gk"
                                                           @if(!empty($form->ill_sy_gk)) checked @endif
                                                           class="field_ill_sy_gk _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>声音高亢多言</span>
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                <input type="text" name="ill_sy_ot" value="{{ $form?->ill_sy_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                            </div><!-- 第一行结束 -->

                            <!-- 第二行 start -->
                            <div class="row">
                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>面色</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_ms_qh"
                                                           @if(!empty($form->ill_ms_qh)) checked @endif
                                                           class="field_ill_ms_qh _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>面色青灰</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_ms_kcsd"
                                                           @if(!empty($form->ill_ms_kcsd)) checked @endif
                                                           class="field_ill_ms_kcsd _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>口唇色淡</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_ms_msph"
                                                           @if(!empty($form->ill_ms_msph)) checked @endif
                                                           class="field_ill_ms_msph _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>面色偏红</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_ms_ch"
                                                           @if(!empty($form->ill_ms_ch)) checked @endif
                                                           class="field_ill_ms_ch _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>唇红</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_ms_fh"
                                                           @if(!empty($form->ill_ms_fh)) checked @endif
                                                           class="field_ill_ms_fh _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>面色发黄</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_ms_db"
                                                           @if(!empty($form->ill_ms_db)) checked @endif
                                                           class="field_ill_ms_db _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>多斑</span>
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">唇色</i></span></span>
                                                <input type="text" name="ill_ms_ot" value="{{ $form?->ill_ms_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>寒热</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_hr_pl"
                                                           @if(!empty($form->ill_hr_pl)) checked @endif
                                                           class="field_ill_hr_pl _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>多怕冷</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_hr_pr"
                                                           @if(!empty($form->ill_hr_pr)) checked @endif
                                                           class="field_ill_hr_pr _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>多怕热</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_hr_plpr"
                                                           @if(!empty($form->ill_hr_plpr)) checked @endif
                                                           class="field_ill_hr_plpr _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>既怕冷又怕热</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_hr_bplbpr"
                                                           @if(!empty($form->ill_hr_bplbpr)) checked @endif
                                                           class="field_ill_hr_bplbpr _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>不怕冷不怕热</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_hr_pf"
                                                           @if(!empty($form->ill_hr_pf)) checked @endif
                                                           class="field_ill_hr_pf _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>多怕风</span>
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                <input type="text" name="ill_hr_ot" value="{{ $form?->ill_hr_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                            </div>
                            <!-- 第二行 end -->

                            <!-- 第三行 start -->
                            <div class="row">
                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>饮食</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_ys_ysjc"
                                                           @if(!empty($form->ill_ys_ysjc)) checked @endif
                                                           class="field_ill_ys_ysjc _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>食欲较差</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_ys_ysws"
                                                           @if(!empty($form->ill_ys_ysws)) checked @endif
                                                           class="field_ill_ys_ysws _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>食欲旺盛</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_ys_yszc"
                                                           @if(!empty($form->ill_ys_yszc)) checked @endif
                                                           class="field_ill_ys_yszc _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>食欲正常</span>
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                <input type="text" name="ill_ys_ot" value="{{ $form?->ill_ys_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>饮水</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_hs_xwr"
                                                           @if(!empty($form->ill_hs_xwr)) checked @endif
                                                           class="field_ill_hs_xwr _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>喜温热</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_hs_xll"
                                                           @if(!empty($form->ill_hs_xll)) checked @endif
                                                           class="field_ill_hs_xll _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>喜冷凉</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_hs_lrjk"
                                                           @if(!empty($form->ill_hs_lrjk)) checked @endif
                                                           class="field_ill_hs_lrjk _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>冷热均可</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_hs_ky"
                                                           @if(!empty($form->ill_hs_ky)) checked @endif
                                                           class="field_ill_hs_ky _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>渴饮</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_hs_ys"
                                                           @if(!empty($form->ill_hs_ys)) checked @endif
                                                           class="field_ill_hs_ys _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>饮少，不渴饮</span>
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                <input type="text" name="ill_hs_ot" value="{{ $form?->ill_hs_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                            </div>
                            <!-- 第三行 end -->

                            <!-- 第四行 start -->
                            <div class="row">
                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>大便</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_db_cy"
                                                           @if(!empty($form->ill_db_cy)) checked @endif
                                                           class="field_ill_db_cy _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>成形</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_db_bcy"
                                                           @if(!empty($form->ill_db_bcy)) checked @endif
                                                           class="field_ill_db_bcy _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>不成形</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_db_gzjk"
                                                           @if(!empty($form->ill_db_gzjk)) checked @endif
                                                           class="field_ill_db_gzjk _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>干燥结块</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_db_bm"
                                                           @if(!empty($form->ill_db_bm)) checked @endif
                                                           class="field_ill_db_bm _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>便秘</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_db_fx"
                                                           @if(!empty($form->ill_db_fx)) checked @endif
                                                           class="field_ill_db_fx _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>腹泻</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_db_ljhz"
                                                           @if(!empty($form->ill_db_ljhz)) checked @endif
                                                           class="field_ill_db_ljhz _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>里急后重</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_db_zc"
                                                           @if(!empty($form->ill_db_zc)) checked @endif
                                                           class="field_ill_db_zc _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>正常</span>
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                <input type="text" name="ill_db_ot" value="{{ $form?->ill_db_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>睡眠</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_sm_sm"
                                                           @if(!empty($form->ill_sm_sm)) checked @endif
                                                           class="field_ill_sm_sm _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>失眠</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_sm_smq"
                                                           @if(!empty($form->ill_sm_smq)) checked @endif
                                                           class="field_ill_sm_smq _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>睡眠浅</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_sm_dm"
                                                           @if(!empty($form->ill_sm_dm)) checked @endif
                                                           class="field_ill_sm_dm _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>多梦</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_sm_zc"
                                                           @if(!empty($form->ill_sm_zc)) checked @endif
                                                           class="field_ill_sm_zc _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>正常</span>
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                <input type="text" name="ill_sm_ot" value="{{ $form?->ill_sm_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                            </div>
                            <!-- 第四行 end -->

                            <!-- 第五行 start -->
                            <div class="row">
                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>痰涕</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_tt_sb"
                                                           @if(!empty($form->ill_tt_sb)) checked @endif
                                                           class="field_ill_tt_sb _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>痰涕色白</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_tt_sh"
                                                           @if(!empty($form->ill_tt_sh)) checked @endif
                                                           class="field_ill_tt_sh _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>痰涕色黄</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_tt_c"
                                                           @if(!empty($form->ill_tt_c)) checked @endif
                                                           class="field_ill_tt_c _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>稠</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_tt_x"
                                                           @if(!empty($form->ill_tt_x)) checked @endif
                                                           class="field_ill_tt_x _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>稀</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_tt_ykc"
                                                           @if(!empty($form->ill_tt_ykc)) checked @endif
                                                           class="field_ill_tt_ykc _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>易咳出</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_tt_bykc"
                                                           @if(!empty($form->ill_tt_bykc)) checked @endif
                                                           class="field_ill_tt_bykc _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>不易咳出</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_tt_no"
                                                           @if(!empty($form->ill_tt_no)) checked @endif
                                                           class="field_ill_tt_no _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>无</span>
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                <input type="text" name="ill_tt_ot" value="{{ $form?->ill_tt_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>舌像</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="input-group"
                                                     style="margin-top: 10px; margin-right: 10px; width: 130px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">舌质</i></span></span>
                                                    <input type="text" name="ill_sx_sz" value="{{ $form?->ill_sx_sz }}"
                                                           class="form-control field_name _normal_" placeholder="输入 其他">
                                                </div>

                                                <div class="input-group"
                                                     style="margin-top: 10px; margin-right: 10px; width: 130px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">舌苔</i></span></span>
                                                    <input type="text" name="ill_sx_st" value="{{ $form?->ill_sx_st }}"
                                                           class="form-control field_name _normal_" placeholder="输入 其他">
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                <input type="text" name="ill_sx_ot" value="{{ $form?->ill_sx_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                            </div>
                            <!-- 第五行 end -->

                            <!-- 第六行 start -->
                            <div class="row">
                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>月经</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="input-group"
                                                     style="margin-bottom: 8px; margin-right: 10px; width: 130px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">周期</i></span></span>
                                                    <input type="text" name="ill_yj_zq" value="{{ $form?->ill_yj_zq }}"
                                                           class="form-control field_name _normal_" placeholder="输入 周期">
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_yj_ld"
                                                           @if(!empty($form->ill_yj_ld)) checked @endif
                                                           class="field_ill_yj_ld _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>量多</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_yj_ls"
                                                           @if(!empty($form->ill_yj_ls)) checked @endif
                                                           class="field_ill_yj_ls _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>量少</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_yj_sd"
                                                           @if(!empty($form->ill_yj_sd)) checked @endif
                                                           class="field_ill_yj_sd _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>色淡</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_yj_sa"
                                                           @if(!empty($form->ill_yj_sa)) checked @endif
                                                           class="field_ill_yj_sa _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>色暗</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_yj_xk"
                                                           @if(!empty($form->ill_yj_xk)) checked @endif
                                                           class="field_ill_yj_xk _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>淤血块</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_yj_xz"
                                                           @if(!empty($form->ill_yj_xz)) checked @endif
                                                           class="field_ill_yj_xz _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>胸胀</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_yj_tj"
                                                           @if(!empty($form->ill_yj_tj)) checked @endif
                                                           class="field_ill_yj_tj _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>痛经</span>
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                <input type="text" name="ill_yj_ot" value="{{ $form?->ill_yj_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>白带</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="input-group"
                                                     style="margin-bottom: 8px; margin-right: 10px; width: 150px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">颜色</i></span></span>
                                                    <input type="text" name="ill_bd_ys" value="{{ $form?->ill_bd_ys }}"
                                                           class="form-control field_name _normal_" placeholder="输入 其他">
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_bd_ld"
                                                           @if(!empty($form->ill_bd_ld)) checked @endif
                                                           class="field_ill_bd_ld _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>量大</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_bd_ls"
                                                           @if(!empty($form->ill_bd_ls)) checked @endif
                                                           class="field_ill_bd_ls _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>量少</span>
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                <input type="text" name="ill_bd_ot" value="{{ $form?->ill_bd_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                            </div>
                            <!-- 第六行 end -->

                            <!-- 第七行 start -->
                            <div class="row">
                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span>精神<br/>状态</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_js_kfpb"
                                                           @if(!empty($form->ill_js_kfpb)) checked @endif
                                                           class="field_ill_js_kfpb _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>困乏疲惫</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_js_kfzd"
                                                           @if(!empty($form->ill_js_kfzd)) checked @endif
                                                           class="field_ill_js_kfzd _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>亢奋躁动</span>
                                                </div>

                                                <div class="vs-checkbox-con vs-checkbox-primary"
                                                     style="margin-right: 16px">
                                                    <input value="1" name="ill_js_zc"
                                                           @if(!empty($form->ill_js_zc)) checked @endif
                                                           class="field_ill_js_zc _normal_ Dcat_Admin_Widgets_Checkbox"
                                                           type="checkbox"><span class="vs-checkbox vs-checkbox-">
                                                        <span class="vs-checkbox--check"><i
                                                                class="vs-icon feather icon-check"></i></span></span>
                                                    <span>正常</span>
                                                </div>

                                            </div>

                                            <div class="input-group" style="margin-top: 10px; width: 200px;">
                                                    <span class="input-group-prepend"><span
                                                            class="input-group-text bg-white"><i
                                                                class="feather">其他</i></span></span>
                                                <input type="text" name="ill_js_ot" value="{{ $form?->ill_js_ot }}"
                                                       class="form-control field_name _normal_" placeholder="输入 其他">
                                            </div>

                                        </div>
                                    </div>

                                </div>

                                <div class="col-md-6">
                                    <div class="form-group row form-field">
                                        <div class="col-md-2 text-capitalize control-label"><span></span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>

                                            <div class="input-group">

                                            </div>

                                        </div>
                                    </div>

                                </div>

                            </div>
                            <!-- 第七行 end -->

                            <hr/>

                            <div class="row">
                                <div class="col-md-12 ">
                                    <div class="form-group row form-field">
                                        <div class="col-md-1 text-capitalize control-label"><span>评估总结</span></div>
                                        <div class="col-md-10 ">
                                            <div class="help-block with-errors"></div>
                                            <div class="input-group">
                                                <textarea type="text" name="summary" rows="5"
                                                          class="form-control field_name _normal_"
                                                          placeholder="输入 评估总结">{{ $form?->summary }}</textarea>
                                            </div>
                                        </div>
                                    </div>
                                </div>
                            </div>

                        </div>

                    </div>

                    <!-- Footer -->
                    <div class="box-footer">
                        <div class="col-md-12">
                            <div class="btn-group pull-right">
                                <button class="btn btn-primary submit"><i class="feather icon-save"></i> 提交</button>
                            </div>
                            <div class="btn-group pull-left">

                            </div>
                        </div>
                    </div>
                </div>
            </form>
        </div>
    </div>
</div>

<script>
    Dcat.init('#form-fitness .field_birthday._normal_', function (self) {
        self.datetimepicker({"format": "YYYY-MM-DD", "locale": "zh_CN", "allowInputToggle": true});
    });
</script>


{!! admin_js('vendor/dcat-admin/dcat/plugins/layer/layer.js?v2.2.2-beta') !!}
{!! admin_js('vendor/dcat-admin/dcat/plugins/jquery.initialize/jquery.initialize.min.js?v2.2.2-beta') !!}
{!! admin_js('vendor/dcat-admin/dcat/plugins/moment/moment-with-locales.min.js?v2.2.2-beta') !!}
{!! admin_js('vendor/dcat-admin/dcat/plugins/bootstrap-datetimepicker/bootstrap-datetimepicker.min.js?v2.2.2-beta') !!}
{!! admin_js('vendor/dcat-admin/dcat/plugins/select/select2.full.min.js?v2.2.2-beta') !!}


